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182
Closed Haemorrhoidectomy
(Ferguson Procedure)
This surgical technique developed by Ferguson
and Heaton in 1959 (Rosa) was conceived with
the aim of overcoming the common disadvan-
tages attributed to open haemorrhoidectomy
[ 88 ]. The authors had the aim of removing most
of the haemorrhoidal tissue while sparing the
anoderm, reducing postoperative serous secre-
tions and preventing stenosis following healing
by second intention. To date, this is still the
haemorrhoidectomy technique most frequently
used in the United States.
Technique
Closed haemorrhoidectomy can be performed
under any type of anaesthesia. In case of local
anaesthesia, the drug of choice is bupivacaine
with adrenaline. Regional anaesthesia with cau-
dal block and subarachnoid anaesthesia are also
among the possible options.
Although the procedure is performed by
some surgeons with the patient in gynaecologi-
cal position and although Ferguson himself, in
describing his original technique, suggested to
position the patient in Sims position, the genu-
pectoral position (jackknife) is currently the
one which is most widely used. The buttocks
are spread apart with adhesive tape to better
expose the anal region. The area is disinfected
with iodine solution, and there is no need for
hair removal. The anal canal is explored with a
Pratt bivalve anoscope in order to allow the sur-
geon to evaluate in which and in how many
quadrants haemorrhoidectomy is necessary. In
fact, although the three- quadrant haemorrhoid-
ectomy including the anterior, right posterior
and left lateral regions is the most common one,
it is not the rule at all. Generally, after explora-
tion with the Pratt anoscope, a Fansler opera-
tive anoscope will be inserted; thanks to a
fenestration running over the whole length of
the anoscope, this device allows avoiding an
excessive excision of the anal epithelium, help-
ing to prevent stenosis. The anoscope is posi-
tioned in line with the haemorrhoidal plexus to
be resected.
The haemorrhoidal plexus and relative anal
tag which may be adjacent to it are grasped with
a forceps and drawn upwards and towards the
centre of the anal canal. With Metzenbaum scis-
sors the tissue below the forceps is incised, from
the skin towards the centre of the anus, paying
attention to keep the internal sphincter fi bres
away. Usually the most voluminous haemor-
rhoidal plexus is excised fi rst. After separating
the haemorrhoidal plexus from the internal
sphincter over its whole extension, the surgeon
proceeds to the ligation/section or to the dia-
thermy coagulation of the vascular pedicle. An
absorbable suture is used to close the surgical
wound completely.
In order to keep the risk of stenosis as low as
possible, the surgeon generally performs wound
closure with the anoscope in situ.
Submucosal Haemorrhoidectomy
(Parks Procedure)
Parks [ 89 ] describes this procedure in 1956. It is
substantially an excision of haemorrhoidal tissue
performed after incision of the mucosa inside the
anal canal and the rectum, followed by mucosal
suture: the aim is to reduce healing time and the
rate of stenosis.
Technique
Any anal retractor can be used. Also for this pro-
cedure, it can be useful to infi ltrate the area to be
treated with a solution containing adrenaline. The
incisions are performed starting from the skin
just outside the anal verge, and exerting traction
on the skin just beyond the external margin of the
wound, the incision is then extended upwards
including the rectal mucosa above the haemor-
rhoid up to 4 cm from the mucocutaneous junc-
tion. The haemorrhoidal tissue is exposed and
separated from the mucosal folds and from the
underlying muscular plane and then removed
after being transfi xed and tied in proximity of the
vascular pedicle. The mucosal folds within the
anal canal are reapproximated. The margins of
the anoderm below and the rectal mucosa above
next to the pedicle ligatures are left open.
A. Longo et al.
183
Circular Haemorrhoidectomy
(Whitehead Procedure)
Described for the fi rst time by Whitehead 130
years ago [ 90 ], circular haemorrhoidectomy was
initially met with keen interest mainly in the
United Kingdom but has now been abandoned
almost completely, mostly because of its diffi cult
technical execution.
Technique
The procedure originally described by the author
implies a circular incision at the level of the den-
tate line for each plexus to treat. Through this
incision, the surgeon proceeds, moving upwards,
to the dissection of the haemorrhoidal tissue.
After completing ligation of the vascular pedicle,
the haemorrhoidal plexus is removed, and the
surgeon proceeds to suture the mucosa to the anal
canal at the level of the dentate line.
In a wrong interpretation of the descriptions
given by Whitehead, many surgeons sutured the
mucosa to the skin at the external anal margin.
Apart from leading to frequent dehiscences of the
sutures caused by excessive tension, this techni-
cal error often resulted in a deformity of the anus
characterised by the protrusion of the anal
mucosa out of the external anal margin. This
complication, consisting of a mucosal ectropion,
has become known as “Whitehead deformity”,
making the illustrious colleague more notorious
for a complication for which he was not respon-
sible than for the procedure fi rst described by
him.
Results
Whenever the technique is performed following
the original indications given by Whitehead the
reported results are similar to those of other
haemorrhoidectomies. Bonello [ 91 ], Wolff and
Culp [ 92 ], Barrios and Khubchandani [ 93 ] agree
with this.
Comment on Haemorrhoidectomy
The purpose of surgical haemorrhoidectomy has
always been that of removing haemorrhoids as
radically as possible, with the minimum possible
postoperative pain and limited complications.
The Whitehead procedure certainly is the one
that allows the most complete excision of haem-
orrhoidal tissue, but it has never been well
accepted because of the anal deformity of the
same name. In reality, this is an iatrogenic muco-
sal ectropion due to the suture placed between the
anal mucosa and the dentate line or, by mistake,
the anal skin. An almost constant complication of
this procedure is anal incontinence, varying from
moist anus to faecal incontinence. For those who
have no direct experience of the Whitehead pro-
cedure, it is suffi cient to remember that these
sequelae are comparable to those of ultra-low
coloanal anastomosis. These complications give
us the chance to comment on something I suggest
we should keep in mind: removal of haemor-
rhoids and of anal mucosa implies that the anal
canal becomes lined with rectal mucosa; rectal
mucosa directly secretes mucus outwards, caus-
ing soiling; the rectal contents can no longer be
adequately discerned by the receptors of the anal
mucosa, and the haemorrhoidal cushions can no
longer play their role in improving the closure of
the anus so that continence ends up being
weakened.
Two banal conclusions can be drawn from the
considerations above: in order to adequately per-
form a retaining function, the muscular anal canal
must be covered with anal skin and mucosa,
while the haemorrhoids improve this function. In
grade IV haemorrhoidal prolapse, the anal canal
is covered, entirely or in part, by rectal mucosa
prolapsed into the anus which frequently causes
soiling. Soiling consists of mucus with a high
bacterial load, variable PH and a number of dis-
solved substances. For this reason mucus can
cause bacterial, chemical and also fungal derma-
titis. As soiling and dermatitis are caused by
haemorrhoidal prolapse, they should be consid-
ered correlated symptoms. Hence, surgical treat-
ment of haemorrhoidal disease should also aim at
healing soiling and pruritus, and the effi ciency of
a technique should also be evaluated in relation
to the resolution of these symptoms. Instead, in
the literature these symptoms are rarely taken
into consideration pre- and postoperatively.
14 Ope rative Managem en t
184
Much confusion clearly exists about haemor-
rhoidal disease when it comes to determining its
specifi c symptoms.
All the longitudinal haemorrhoidectomies –
Milligan-Morgan, Fergusson, etc. – imply the
removal of longitudinal folds of anal mucosa
covering the haemorrhoids. These mucosal folds
are the ones that mainly allow the anus to dilate,
because they are not directly adherent to the
sphincters. Therefore, haemorrhoidectomy inevi-
tably entails a reduction of anal dilatability.
In a certain percentage of cases, which var-
ies considerably in the literature, this defi cit is
pathological. The tight anal stenoses are due to
the almost complete excision of the anal skin
and mucosa. The procedures for rotation and
sliding of perineal cutaneous fl aps restore the
anal lumen more or less satisfactorily. But
because this type of tissue is not specialised in
sensory discrimination and these fl aps have no
receptors connected to the anal sphincters, the
continence function, including the anal opening
and closing refl ex, results severely and defi -
nitely compromised and so is the patients’ qual-
ity of life.
Severe anal stenosis is reported in the litera-
ture at very variable rates. It certainly is an
uncommon complication, although there is a
feeling that this problem is underestimated. In
fact if every proctologist compared the cases of
stenosis (obviously occurring in patients oper-
ated on elsewhere!) that he had to manage with
the overall number of haemorrhoidectomies per-
formed, he would come to the conclusion that his
data are not consistent with data reported in the
literature.
The historical problem with haemorrhoidecto-
mies is postoperative pain and the long healing
time. A very high proportion of patients refuse
haemorrhoidectomy even though they have sig-
nifi cant symptoms because they know that post-
operative recovery is extremely painful. And
there is no doubt that this is the popular opinion
about this procedure. This leads patients to try
whichever remedy in the hope of avoiding an
operation. Therefore, tons of rectal ointments and
drugs are being used all over the world every day.
The result of this is an incalculable waste of
money, with frequent iatrogenic damages which
are often worse than the disease itself. Very prob-
ably this widespread opinion on haemorrhoidec-
tomy has not changed substantially despite our
efforts to reassure patients and allay their fears.
Certainly postoperative recovery has become sig-
nifi cantly more tolerable. It still remains to be
clarifi ed whether this is owed to more effective
antalgic therapies or to the innovative techniques
and technologies proposed. In order to under-
stand and control post-haemorrhoidectomy pain,
it is imperative to understand what postoperative
incidents are causing it and if these traumas can
be modifi ed by adopting different forms of energy
for tissue dissection.
Understanding the origin of post-
haemorrhoidectomy pain is not easy at all, and
there is a risk of being sidetracked by studies that
in the last decades have created many expecta-
tions and just as many disillusions. The ordinary
post-haemorrhoidectomy wound is made up of a
muscular base consisting of corrugator ani and
smooth sphincter and of two severed margins
consisting of anoderm, mucosa and submucosa.
The smooth sphincter contains only pressure
receptors and is not traversed by sensory fi bres
directed to the anal mucosa, as these come from
the rectum. This means that the only pain sensa-
tion perceivable by the smooth sphincter is either
caused by specifi c stimulation of the pressure
receptors or by an aspecifi c stimulus to the sec-
tioned and exposed nerve terminations. The same
considerations apply to the mucosa of the anal
canal which has few pain and temperature recep-
tors but is endowed with pressure receptors. In
fact the only form of pain perceivable in the anal
mucosa and haemorrhoids is tensive pain caused
by tissue distension, as, for example, in case of
thrombosis, oedema or strangulation following
RBL. This is confi rmed by the fact that any pro-
cedure performed above the anoderm is almost
painless. Thus the site of post- haemorrhoidectomy
pain is in all likelihood the dermal-anodermal
region. This region with its very dense somatic
innervation contains numerous receptors special-
ised towards both physical stimuli, like tempera-
ture, stretching and pressure, and chemical
stimuli, mainly PH.
A. Longo et al.
185
The idea that the energy adopted for tissue
excision (monopolar diathermy, laser, Ultracision,
LigaSure) can modify postoperative pain has been
and is still being advocated with much emphasis.
This conviction can be rebutted with a few obvi-
ous considerations. If the use of a type of energy
that develops little heat improves pain, it would be
ideal to incise and excise the anal skin with a cold
scalpel blade to avoid heat-related tissue damage.
Clinical experience tells us otherwise. The ther-
mal receptors are stimulated by temperatures dif-
ferent from those typical of the body, both hot and
cold, and only when this difference becomes
remarkable, the stimulus is perceived and trans-
mitted as painful. There is no doubt that, which-
ever temperature the tissue reaches during the
procedure, the patient does not perceive pain
thanks to anaesthesia; after a few minutes, this tis-
sue resumes normal body temperature and so the
patient cannot feel pain generated from heat.
It could be objected that there is also signifi -
cant biological damage to the residual anoderm
and the perianal skin, but here too the consider-
ation that the use of a cold blade, with selective
coagulation or ligation of the vessels, should
cause less damage and less pain, is valid. It
should be remembered that tissue repair, both by
fi rst intention (closed haemorrhoidectomies) and
by second intention (open haemorrhoidectomy)
happens thanks to fi brin, fi broblasts and other
repair factors exuding from arterial, venous and
lymphatic capillaries and deposited on the injured
surfaces. This might cause a delay in scarring,
and I do think that this is not an unfounded
assumption. This adverse event, which has been
described in closed haemorrhoidectomies (refer-
ences), strangely is not reported in the case of
Milligan-Morgan procedures.
Experience and data from the literature con-
fi rm that the type of energy used do not infl uence
pain. For many years countless papers – whether
entirely objective or not – have been reporting
signifi cantly better results with the use of a laser.
These results have since been irrefutable dis-
proved by subsequent more reliable studies.
I am convinced that all the other forms of
energy currently proposed for haemorrhoidec-
tomy will be facing the same fate as laser.
Unitary Theory of Rectoanal Prolapse
In order to introduce the principles of stapled
haemorrhoidopexy (SH) and stapled transanal
rectal resection (STARR), I think it is useful to
briefl y present the considerations, clinical obser-
vations and original studies which form the ratio-
nal basis of these techniques.
At the beginning of the 1990s, after perform-
ing hundreds of Milligan and Morgan, Ferguson,
Whitehead and other procedures, I realised that
the postoperative period was a very painful expe-
rience for patients and that the sad notoriety of
these procedures induced many persons to
exclude surgery.
Initially I developed an inferiority complex,
thinking I was not able to perform the technique
correctly, but later on, after having visited
renowned coloproctology centres, I understood
that I was obtaining the same results they did and
that there was – and is even more so today – an
enormous discrepancy between clinical reality
and publication of results. I became convinced
that a haemorrhoidectomy, whether closed, open,
semi-closed or other, did not represent an ade-
quate therapeutic response to the problem.
Through the simple analysis of and extensive
refl ections on the literature, I sensed that the very
essence of haemorrhoidal pathology had still not
been captured. I came across some incoherences
and contradictions that represented a stimulus for
me to study of the problem more in depth.
Thomson [ 1 ] thought that the disruption of the
haemorrhoids’ supportive tissue caused prolapse.
Haas et al. [ 2 ], in 1984, demonstrated that haem-
orrhoidal supportive tissue disintegrates in all
subjects after the age of 30, but not everyone has
symptomatic haemorrhoids or prolapse.
This information matches the clinical obser-
vation that haemorrhoidal prolapse is always
associated to rectal mucosal prolapse, that can
protrude into the anal canal and then outside the
anus. The external prolapse of rectal mucosa is
permanent in the so-called fourth-degree pro-
lapse, and so it is clinically comparable to an
ectropion.
Non-reducible rectal mucosa prolapse is thus
certainly the cause of soiling which in turn causes
14 Ope rative Managem en t
186
perianal dermatitis and hence pruritus. Where
and how does rectal mucosa, which prolapses
together with the haemorrhoids, return to within
the rectum at the end of evacuation in the case of
second- and third-degree prolapses?
To answer this question, we performed a defe-
cography in all patients with haemorrhoidal pro-
lapse of grades II, III and IV in addition to routine
proctoscopy. The result was that all patients with
any degree of haemorrhoidal prolapse presented
a rectoanal invagination whose size could not be
correlated with the size and grade of the external
prolapse.
Moreover, in women a rectocele was almost
always associated to rectoanal invagination.
Rectoanal invagination and rectocele associated to
haemorrhoidal prolapse explain the previously
unclear correlation between haemorrhoidal dis-
ease, straining and obstructed defecation (OD). If
we consider the consistent association of haemor-
rhoidal prolapse and rectal prolapse, we can
exclude that this is just an occasional concomi-
tance of two distinct pathologies as has always
have been thought and written. Clearly this must
be a clinical and pathological picture of its own.
What still had to be determined was a cause- effect
relationship: is it the haemorrhoids that, when pro-
lapsed, draw the rectal mucosa down, or is it the
rectal prolapse that pushes the haemorrhoids out
of the anus? There was no doubt for us that the
second hypothesis had to be correct. In fact it is
impossible to fi nd a haemorrhoidal prolapse with-
out rectal prolapse, while the opposite is frequently
observed. We came up with the theory that recto-
anal invagination causes a kink in the superior
haemorrhoidal veins which hampers haemor-
rhoidal venous outfl ow and leads to dilatation of
the haemorrhoids. This dilatation and stretching of
the haemorrhoids can cause increased friction and
mechanical trauma to the overlying mucosa during
the passage of faeces, with subsequent de-epitheli-
sation and bleeding. We think that this clinical
condition constitutes what it is defi ned rather fuzz-
ily as fi rst-degree haemorrhoidal prolapse.
Subsequently rectal invagination extends to
the anal canal during evacuation, causes its
obstruction and induces increased straining. It is
easy to imagine but also demonstrable in dynamic
cinedefecography how the faecal bolus pushes
both rectal prolapse and haemorrhoids out of the
anal canal with force. In fact, only once the pro-
lapse is expelled, the anal canal is cleared and
evacuation can start.
The above-mentioned clinical studies have led
us to a revolutionary conclusion that is in confl ict
with all the traditional ideas on the pathogenesis
of haemorrhoidal disease: haemorrhoidal pro-
lapse and all its related symptoms constitute a
pathology secondary to the internal rectal pro-
lapse; the rupture of the supportive tissue of the
haemorrhoids is a necessary, but not suffi cient,
precondition for a prolapse to occur. In fact, rup-
ture of supporting fi bres is a physiological phe-
nomenon typical of aging (Haas [ 2 ]) and it does
not necessarily imply haemorrhoidal prolapse.
Seemingly, in young subjects the rupture of the
Treitz fi bres is caused when the rectal prolapse
repeatedly pushes against the haemorrhoidal
cushions. Haemorrhoidal prolapse is therefore
only one of a number of possible clinical mani-
festations of an internal rectal prolapse.
This new theory explains the correlation between
haemorrhoidal disease and obstructed defecation.
In fact, rectoanal invagination is also the main cause
of the obstructed defecation syndrome.
The limited scope of this chapter does not
allow us to go into detail about all the clinical
aspects related to rectoanal prolapse and the stud-
ies that led us to some conclusions. It is however
necessary to give at least a short summary in
order to explain the rational basis of the tech-
niques for the therapy of haemorrhoidal prolapse
that we are about to describe. Internal rectal pro-
lapse, whether associated or not to anal, mucosal
and haemorrhoidal prolapse, can be a mucosal
rectal prolapse (about 10 % of our cases) or a
full-thickness rectal prolapse.
When performing a baseline 2-view X-ray of
the empty rectum with barium contrast, we can
see that some patients present with a rectum the
shape of which, especially distally, indicates a
detachment from the sacral-coccygeal plane; this
type of rectum is usually folded on itself, with
unnatural loops lying on the perineum, and is
longer than usual. We have called this conforma-
tion “rectal redundancy”.
A. Longo et al.
187
When performing a varied dynamic rectal vid-
eodefecography in patients with rectal redun-
dancy, i.e. with only the sigmoid fi lled with
barium and potato starch, we note that such a
redundancy always causes an obstacle to the
transit of barium into the rectal lumen, causing
more intense straining and repeated attempts at
evacuating.
During straining it is possible to observe how
this rectal redundancy can assume different mor-
phological aspects including various combina-
tions: simple or multiple invagination, rectocele
caused by rectal dilatation or by formation of a
loop and partial or total outward expulsion of the
rectum.
In patients with haemorrhoidal prolapse, a
good impregnation of the anal canal allows to
visualise how a rectoanal invagination pushes
haemorrhoids and anal mucosa outside. It is also
interesting to observe that in some patients a
descent of the Douglas pouch or formation of an
enterocele can be seen during straining; by com-
pressing the rectum from above and pushing it
towards the sacrum, this facilitates emptying of
the rectal contents.
Enterocele and Douglas pouch dislocation are
always associated to an excessive perineum low-
ering. These pelvic alterations can disappear
completely or partially and can persist at the end
of straining. With regard to their behaviour, we
have divided these pelvic alterations into stable
and dynamic ones. They are indeed caused by
excessive straining and in our opinion should be
considered supporting mechanisms compensat-
ing for the incapacity of a prolapsed rectum to
empty physiologically.
With regard to the nature of the rectocele,
I would like to point out that cadaveric studies
and ultrasonographic mapping of the rectum in
patients with a similar clinical and defecographic
picture have clearly demonstrated that the only
perceivable alteration is the thinning or disap-
pearance of the muscular layer of the rectum.
This type of defect begins just above the anal
canal and extends variably upwards. As the rectal
ampulla is no longer effectively supported by the
muscular layer, it can expand anteriorly and,
after occupying the perineal body, push onto the
posterior vaginal wall, causing a colpocele. Large
rectoceles can dilate the vaginal wall abnormally
causing secondary structural damage. In any
case, a rupture of the famous rectovaginal septum
– the defi nition, function and existence of which
have always been controversial – cannot be con-
sidered a primary cause of rectocele. In numer-
ous cadaveric dissections, we have actually never
been able to detect such a septum, and we there-
fore think that this is probably a wrong defi nition
given by gynaecologists (out of self-interest?).
We have recently received a clear confi rmation of
this theory by pathologists who never detected
such a “septum” in specimens sent in by gynae-
cologists. We thought that these – unfortunately
rather detailed – preliminary remarks were nec-
essary to make the following conclusion under-
standable: haemorrhoidal prolapse is a pathology
secondary to and consequent upon rectal pro-
lapse, be it only mucosal or full thickness.
We therefore consider the clinical and patho-
logical distinction between haemorrhoidal dis-
ease, rectal prolapse and rectocele an artifi cial
one. Although the haemorrhoidal prolapse is the
pathological alteration that causes the typical
symptoms of haemorrhoidal disease, it must be
considered simply an external manifestation of a
prolapse of – initially – the rectum that subse-
quently and progressively can cause a prolapse of
the anal mucosa, the haemorrhoidal cushions and
the anoderm. Not always does an internal rectal
prolapse cause a mucous and haemorrhoidal pro-
lapse associated to it, but all haemorrhoidal pro-
lapses are invariably associated to rectal prolapse.
For this reason a more correct defi nition would
be that of a rectoanal prolapse which would pro-
vide a more correct description of the anatomical
and pathological condition. An in-depth revision
of these pathologies and a clinical reclassifi cation
based on a new theoretical foundation is there-
fore necessary. We have proposed a single com-
bined classifi cation of these pathologies termed
“unitary theory of rectoanal prolapse”.
Based on the results of our studies and our
observations, we came to the conclusion that a
treatment consisting of the correction of internal
rectal prolapse could also represent a rational
treatment for haemorrhoidal prolapse, as it would
14 Ope rative Managem en t
188
cure the cause that determines it. Moreover, the
resection of the internal rectal prolapse would
also resolve obstructed defecation if present, both
because it would eliminate the mechanical obsta-
cle and because resection of the distal rectum
would include removing any rectoceles present,
leading to improved of rectal compliance. Given
the focus of this chapter, we will limit ourselves to
stressing the fact that bleeding, thrombosis and
haemorrhoidal oedema are only a few of the pos-
sible symptoms of the prolapses defi ned as recto-
anal, and therefore obstructed defecation and
continence disorders have to be taken into consid-
eration when taking the history of these patients.
The rectal prolapse associated to a haemor-
rhoidal prolapse can present with different sizes,
and there is no correlation in terms of size between
haemorrhoidal and rectal prolapse. For this reason
the simple clinical evaluation of an external haem-
orrhoidal prolapse is not predictive of the size of
the rectal prolapse that has to be removed, and so
it does not allow us to determine the technique
that needs to be chosen. Histologically, a simple
mucosal prolapse is a detachment of mucosa and
submucosa from the muscular layer of the rectum,
and given their increased length, it presents as a
redundancy. Full-thickness prolapse is generally
characterised by a lengthening of the rectum
because of structural alterations of the muscular
layers. The rectum tends to form multiple loops
that fold on themselves. In other cases rectal pro-
lapse can be due to slippage of the whole rectum-
sigmoid. In this case the natural evolution is a
complete external rectal prolapse. Mucous rectal
prolapses can be resected with the stapled ano-
pexy technique. STARR is reserved to large
mucosal prolapses or to full-thickness prolapses.
STARR can be performed by means of two PPH
devices or with the more recently introduced
curved stapler that goes by the (unfortunate) name
of TRANSTAR.
Stapled Haemorrhoidopexy (SH)
Technique
Also known as the PPH procedure, Longo pro-
cedure, stapled anopexy and circumferential
mucosectomy, PPH is a technique developed in
1993 that reduces the prolapse of haemorrhoidal
tissue by excising a doughnut-like ring of the
prolapsed rectal mucosa with a circular stapling
device: with this the haemorrhoidal cushions,
anal mucosa and anoderma are lifted and per-
manently fi xed in their anatomical position [ 94 ],
and a haemorrhoidal prolapse during defecation
is prevented.
The procedure can be performed under sub-
arachnoid anaesthesia; the patient is placed in
lithotomic position. A PPH-01 or PPH-03 kit
(Ethicon Endo-Surgery, Cincinnati, Ohio) is nec-
essary. The introduction of the circular anal dila-
tor (CAD) causes the reduction of the anal
prolapse into the rectum. After removing the
obturator, the prolapsed rectal mucosa falls into
the lumen of the dilator. The purse-string ano-
scope (PSA) is then introduced through the dila-
tor. This anoscope will push the prolapsing
mucosa back against the rectal wall along a 270°
circumference, while the mucous membrane that
protrudes through the anoscope window can be
easily captured with a stitch (Prolene TM 00,
Ethicon). By rotating the anoscope, it will be pos-
sible to complete a purse-string suture around the
entire rectal circumference, 2–3 cm above the
haemorrhoidal apex.
A PPH-01/PPH-03 stapler is opened to its
maximum position. Its head is introduced until
crossing the purse-string which is then tied
with a knot. The ends of the suture are knotted
externally. Then the stapler is partially tight-
ened while keeping the casing outside. Once
half the casing is inserted into the CAD, it is
pushed against the purse-string, and while
exerting moderate traction on the ends of the
suture, the instrument is tightened. Keeping the
stapling device in the maximum closed posi-
tion, for approximately 30 s, may improve the
haemostasis. Firing the stapler releases a dou-
ble staggered row of titanium staples through
the tissue. The circular stapler knife excises the
tissue. A circumferential column of mucosa is
removed. Finally, the staple line is examined
using the anoscope. Additional haemostasis can
be achieved by stitches (Vicryl TM 2-0,
Ethicon).
A. Longo et al.
189
Results
A recent systematic review [ 95 ] has allowed us to
document the fact that a huge number of scien-
tifi c publications are available in the literature
about the PPH procedure: there are 29 publica-
tions [ 96 – 124 ] on 25 randomised clinical trials
comparing PPH stapled haemorrhoidopexy with
conventional haemorrhoidectomy. They included
a total of 1,918 patients, of whom 971 underwent
stapled haemorrhoidopexy (PPH procedure) and
947 had surgical haemorrhoidectomy. The main
results are reported here.
Procedure Time
In the 23 trials [ 96 , 98 , 100 , 102 , 103 , 105 – 124 ]
in which it was possible to calculate, it was found
that the PPH procedure stood out for its signifi -
cantly shorter operating time compared with con-
ventional haemorrhoidectomy [mean operating
time, 17.55 vs. 28.90 min; weighted mean differ-
ence (WMD) – 11.35 min; P = 0.006].
Pain
The PPH procedure caused signifi cantly less post-
operative pain than conventional surgery. Twenty-
three trials [ 96 , 98 , 100 , 102 – 108 , 110 – 112 , 114 ,
115 , 117 – 124 ], reported signifi cantly less pain
after PPH as evidenced by reduction of the pain
scores at rest and on defecation by 42.3 %.
Recovery
There was a faster surgical and functional recov-
ery after stapled haemorrhoidopexy. The PPH
haemorrhoidopexy allowed a faster functional
recovery with shorter time off work (WMD –
8.45 days; P < 0.00001) and earlier return to nor-
mal activities (WMD – 15.85 days; P = 0.03).
Patient Satisfaction
Signifi cantly more patients in the PPH than in the
conventional haemorrhoidectomy group rated
the procedure as satisfactory [93.3 vs. 86.4 %;
odds ratio (OR) 2.33; P = 0.003] [ 98 , 102 , 105 ,
106 , 112 , 119 , 123 ].
Re-intervention
The PPH procedure did not increase the over-
all need of surgical (OR, 1.27; P = 0.4) and
nonsurgical (OR, 1.07; P = 0.82) re-intervention
compared with conventional haemorrhoidectomy
[ 96 , 98 , 100 , 103 – 105 , 107 – 110 , 112 , 114 , 116 –
119 , 121 – 123 ].
Bleeding
There was no signifi cant difference in the amount
of intraoperative bleeding ( P = 0.26) or the inci-
dence of early postoperative bleeding (bleeding
within 24 h of surgery; P = 0.11). At more than 1
day after surgery, the PPH procedure was associ-
ated with signifi cantly less risk of bleeding (9.8
vs. 15.1 %; OR, 0.52 P = 0.001) [ 96 , 100 , 102 –
106 , 108 – 111 , 114 – 116 , 118 , 124 ]. There was no
difference between the groups regarding the need
for readmission as a result of bleeding (OR, 0.63;
P = 0.67), blood transfusion (OR, 0.64; P = 0.54),
or further nonoperative (OR, 4.06, P = 0.08) or
operative interventions for bleeding (OR, 1.02;
P = 0.95).
Perianal Complications
There was no signifi cant difference between the
two procedures regarding early (OR, 1.82;
P = 0.52) [ 21 , 24 , 28 , 30 , 36 ] or late anal stenosis
(OR, 0.69; P = 0.33) [ 96 , 98 , 100 , 103 , 105 , 107 ,
108 , 111 , 112 , 115 , 116 , 124 ], anal fi ssure (OR,
0.93; P = 0.88) [ 96 , 105 , 112 , 114 , 116 , 117 , 123 ,
124 ] or perianal fi stula (OR, 0.25; P = 0.23) [ 107 ,
110 , 112 , 116 , 117 ].
Early Recurrence
There was no signifi cant difference between the
two groups with regard to early postoperative
recurrence (within 6 months) or persistence of
symptoms from haemorrhoids: 24.8 and 31.7 %
after PPH procedure and conventional haemor-
rhoidectomy, respectively (OR, 0.68; P = 0.08)
[ 98 , 108 , 111 , 114 , 117 , 122 , 124 ]. There was no
difference in the need for further operation for
early recurrent haemorrhoids (OR, 0.71;
P = 0.69).
Late Recurrence
The incidence of recurrent haemorrhoids at 1
year or more after surgery was higher after sta-
pled haemorrhoidopexy (5.7 vs. 1 %; OR, 3.48,
P = 0.02). However, the overall incidence of
14 Ope rative Managem en t
190
recurrent or persistent symptoms from haemor-
rhoids was similar in the groups (PPH vs. con-
ventional: 25.3 vs. 18.7 %; OR, 1.57; P = 0.07)
[ 98 , 106 – 108 , 111 , 114 , 117 ].
Quality of Life
Three trials [ 96 , 100 , 109 ] addressed the quality
of life after surgery. There was no signifi cant dif-
ference in quality of life after either surgical pro-
cedure, as both the Short-Form 36 Quality of Life
questionnaires [ 97 , 109 ] and the Eypasch
Gastrointestinal Quality of Life instrument [ 100 ]
showed. However, there was a tendency towards
higher median physical and mental scores after
PPH procedures.
Cost-Effectiveness
Four trials [ 100 , 103 , 109 , 120 ] investigated the
cost-effectiveness of stapled haemorrhoidopexy
compared with conventional surgery. When both
the operating cost and hospital stay charges were
taken into account, conventional haemorrhoidec-
tomy was more expensive than the PPH proce-
dure, although the differences were not
statistically signifi cant [ 103 , 109 ]. Thus, the cost
of the disposable stapler was offset by a shorter
hospital stay. In an Asian study [ 100 ], where hos-
pital charges are less expensive than in the West,
the total medical cost was higher after the PPH
procedure (US $1,283.09 ± T 31.59 vs. US
$921.17 ± 16.85).
In light of all the above-mentioned consider-
ations, PPH stapled haemorrhoidopexy is safe
with many short-term benefi ts, and long-term
results are similar to the conventional procedure.
Stapled Transanal Rectal Resection
(STARR)
Technique
STARR was proposed by Longo in 1998. We
suggest performing the procedure under sub-
arachnoid anaesthesia with the patient in litho-
tomic position.
Two PPH-01 or PPH-03 kits (Ethicon Endo-
Surgery, Cincinnati, Ohio) are necessary. The
anal canal is checked digitally, in order to ensure
optimal relaxation. Any haemorrhoidal prolapse
or procidentia is reduced using a gauze pack
inserted into the anal canal. Four skin stitches
are applied to fi x the circular anal dilator (CAD)
which is lubricated with Vaseline before being
inserted. A swab is inserted and slowly retracted
to assess the extent of the invagination. A spat-
ula is passed through the posterior window of
the CAD to protect the posterior rectal wall.
A purse- string suture anoscope (PSA) is used to
place 2–3 anterior semicircular sutures (Prolene
TM 00, Ethicon) between 9 and 3 o’clock, the
most caudal one 2–3 cm above the haemor-
rhoidal apex, the following ones in 2 cm steps.
The homolateral threads are tied under moderate
tension. A lubricated maximally opened stapler
is introduced with the head passing beyond the
sutures. The bundled threads are pulled through
the holes of the casing and clamped. Keeping
the stapler head in a stable position while the
threads are pulled tight, the stapler is partially
closed until the resistance of the fi rst suture is
felt. By that it is ensured that the edge of the
casing is placed above the haemorrhoids and
anal ring. Prior to full stapler closure, a vagi-
nal spatula is inserted, and using two fi ngers the
integrity of the vaginal wall is checked. The sta-
pler is closed, fi red and removed. Lateral “dog
ears” joined by a small bridge which has to be
cut are observed frequently. In case of relevant
bleeding, haemostatic stitches (Vicryl TM 2-0,
Ethicon) are applied. The spatula is now repo-
sitioned to protect the anterior rectal wall. The
fi rst posterior semicircular suture is placed
starting from the base of the left dog ear and
moving on to the right dog ear, the second one
from the left dog ear’s apex to the right one. The
posterior prolapse is then resected as described
above. Haemostasis is achieved using haemo-
static stitches and checked carefully.
Please note: The number of anterior sutures is
related to the extension of the invagination. The
semicircular sutures on the anterior and posterior
wall of the rectum can be substituted by a short
running suture. Generally, this option ensures a
more homogeneous traction on the rectal walls
and, at present, is preferred by colorectal sur-
geons in Italy.
A. Longo et al.
191
We suggest to oversew residual dog ears and
to apply four to fi ve stitches to reinforce the ante-
rior and posterior staple line. A strip of Vaseline
gauze tied to a suture should be introduced to
prevent the formation of submucosal haemato-
mas and to facilitate diagnosis of postoperative
bleeding. A urinary catheter was inserted in all
cases.
Results
Recently, in an attempt to prevent the incidence
of failures after SH caused by incomplete resec-
tion of the prolapsed tissue (due to the limited
volume of the stapler casing), the STARR proce-
dure was adopted successfully for those patients
in which a large prolapse was associated with the
haemorrhoidal disease. Boccasanta et al. [ 125 ]
stated that, in patients with an association of pro-
lapsed haemorrhoids and large rectal prolapsed,
STARR results in a more complete resection of
the prolapsed tissue than SH, with equal morbid-
ity and a signifi cantly lower incidence of residual
disease and skin tags. The author used the circu-
lar anal dilator, CAD, in order to determine the
appropriate surgical technique.
Furthermore, as reported in a recent ran-
domised multicentre trial involving more than
400 patients [ 126 ], even if both the PPH-01 and
PPH-03 kit can be used, the use of the PPH-03
stapler instead of the PPH-01 ensures a statisti-
cally signifi cant reduction of intraoperative
bleeding and a signifi cant decrease of operative
time.
Comment on SH and STARR
What emerges clearly from a review of the avail-
able literature on stapled haemorrhoidopexy and
STARR is that many surgeons consider stapled
haemorrhoidopexy a procedure indicated for
haemorrhoidal prolapse and STARR an operation
exclusively indicated in cases of obstructed def-
ecation due to internal rectal prolapse and recto-
cele. Others consider that in case of haemorrhoidal
prolapse, indications for STARR should be lim-
ited to patients with associated OD [ 127 ]. It is
fundamental to revise and adjust these ideas
regarding indications for SH and STARR in order
to obtain optimal results. As said before, haemor-
rhoidal prolapse is always a consequence of an
internal rectal prolapse of variable size and not
correlated to the degree and dimensions of muco-
haemorrhoidal prolapse. This implies that a mod-
est external prolapse can be associated to a
signifi cant internal prolapse. If we perform SH in
these kinds of patients, we will certainly leave a
residual internal rectal prolapse behind. We
believe that this may predispose for a higher rate
of recurrences and may also be the reason why a
possibly associated OD is not cured or, worse,
even aggravated as the residual prolapse can be
jammed inside the anastomosis, especially if a
fi brotic ring forms.
It is therefore important to state clearly that
for haemorrhoidal prolapses, whether symptoms
of obstructed defecation are associated or not,
STARR is the procedure of choice whenever an
important mucosal prolapse is detected and in all
the cases in which there is a full-thickness pro-
lapse or a rectocele. I hope not to shock anyone
by confessing that in the last few years, I have
myself performed STARR in about 95 % of
patients with muco-haemorrhoidal prolapse.
Thanks to this decision the rate of recurrences
has dropped, at 3 years of follow-up, from 4.9 to
0.4 %. Also with regard to curing OD as one of
the complications of this procedure, the results
are much more satisfactory. Paradoxically post-
operative pain and bleeding have also decreased.
In any case, the key aspect is that after so many
years the theory has been proven that haemor-
rhoidal prolapse is secondary to rectal prolapse
and that it can be effectively cured by rectal pro-
lapsectomy sparing the haemorrhoids.
Generally, with regard to the advantages of
SH and STARR, reduced postoperative pain and
faster return to work are frequently highlighted.
In my personal opinion the main advantages are
resolution of OD (which is often associated), effi -
cient outcome regarding soiling and continence,
and the rare incidence of stenosis and, if they
occur, the relatively easy treatment of stenosed
anastomoses. Now that initial scepticism about
SH and STARR as a cure for haemorrhoids has
been overcome, the usual detractors insist on a
14 Ope rative Managem en t